Making it real....
The facts - 2009/10
• Diabetes prevalence 4.1% of population England (2008/9)
• Total spend on diabetes: £649.2 million
• Total number of diabetes items prescribed: 35.5 million
• Net ingredient cost: 7.7% of total cost of prescribing
• 13.2 million Metformin items
• 7.1 million Sulphonylurea items
• Mean number of people with diabetes per pharmacy: 220
• Blood glucose testing strips costs £145.8 million
Reference: NHS Information Centre. Prescription Cost Analysis, England - 2009
The issues
• Diabetes regimen is multidimensional
• More than 95% of diabetes care is managed by the patient
• Many patients do not achieve good glycaemic control
• Risk of complications can be reduced by proper adherence
• Adherence to medication generally better than for lifestyle change; still
estimated to be only around 50%
• Patients often do not adhere to SMBG
• Frustration for healthcare professionals
Cochrane review showed very little effect of nurse led
interventions, home aids, diabetes education and
pharmacy led interventions
The solutions?� Patients to make informed decisions about how they live with their illness
� Patients work towards their own goals
� Roles and responsibilities redefined to match reality of diabetes care
� Patient and HCPs create relationships that promote collaboration and
partnership
� Recognise that patients are experts on their own lives; let go of the
traditional “we know best”
� Use behavioural change techniques providing advice only when patient is
ready to hear and learn more
Once we let go of the issue of non-compliance from our
vision and approach to patients, it disappears as a problem
What should be covered in a type 2
diabetes medicines use review?
• Understand the patient’s view of their treatment and management
• Establish what the patient takes and what they don’t
• Establish what your patient understands about their medicines
• Identify any problems with medicine taking
– Side effects & interactions
– Non-adherence, intentional and unintentional
– Issues with devices
• Identify any broader issues
– Health and wellbeing
– Monitoring of condition
• Support options and offer possible solutions
What should be covered in a type 2
diabetes medicines use review?
What might you uncover?
• Intentional non-adherence
– Denial
– Beliefs – fear,
– Side effects
– Not a priority
– No direct benefit felt
• Unintentional non-adherence
– Complicated regimen
– Confusion
– Cannot swallow, practical difficulties
– Visual impairment
What are the medicine use issues in
type 2 diabetes?
Specific medicine use issues
• Ownership and understanding of their condition and treatment
• Co-morbidities such as hypertension, CVD, neuropathic pain, impaired
renal function
• Use of multiple medicines and multiple dosing regimens
• Use of insulin and associated devices
• Blood glucose control – managing hypos, avoiding hyperglycaemia, linking
treatment to food, exercise and routine
• Self-monitoring of blood glucose
• Importance of lifestyle choices on health outcomes and drug effectiveness
• Overall well-being and mood; anxiety, depression and
poor motivation
• Teenagers and young adults may be more vulnerable
• Social support
It’s not just about medicines
• Varies depending on patient needs and treatment plan
• Local guidance
• Understand any barriers
– Dexterity
– Vision
– Cognitive issues
– Fearful of pain
Health and wellbeing
Case studies
Secondary
Care
Care revolving around the patient
Primary
Care
Checklist
� Prepare
� Understand patient’s current
diabetes management
� Assess medicine use and
management issues
� Support behavioural change
� Offer solutions to support improved adherence and control
(but only after permission)
� Actions as required – you, patient, GP, diabetes nurse
� Remember to signpost
MURs in diabetes - Summary
• Help the patient understand reasons for treatment and benefits of taking (and potential impact if not)
• Recognise different needs of patients who may be taking many other medicines with complex regimes and side effects
• Support patient as part of the local healthcare team; understand local protocols
• Let go of wanting to control
The beauty of empowering others is that your own
power is not diminished in the process
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Additional resources
• Diabetes uk www.diabetes.org.uk
• Diabetes NHS www.diabetes.nhs.uk
• Diabetes travel information www.diabetes-
travel.co.uk
• NHS Choices www.nhs.uk/diabetes
• CPPE www.cppe.ac.uk
• NICE guidance www.nice.org.uk